Wiki Medicare billing rule too many procedures?

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sinman0531

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I know this rule exists, but for the life of me I can't figure out what its called/how to find it.

Basically I have a patient who has come in pretty much every other week from July until September and had some kind of excision or destruction done. One of the claims has 3 lines; a destruction, excision and repair, and they are all denying as inclusive, even though they are not within any global period for the previous date of service. I know that Medicare is saying there were too many procedures done, but I just can't find where it says that.

Help?
 
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Kind of. Basically the patients claim history looks something like this (not including modifiers):

06/30/22
11603
13121

07/09/22
11602
13101
17263

07/12/22
17313
13101

07/21/22
17313
13121

08/09/22
17313
12032

08/18/22
17004
11102

09/12/22
17261
11602
13101



The last date of service is what is denying as inclusive, even though its not within a global period, so the MUE's wouldn't necessarily apply. I know Medicare has a 90-day rolling period where they will only pay on a certain number of procedures, but I cannot find where in their billing rules it says that.
 
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sinman0531 said:
The last date of service is what is denying as inclusive, even though its not within a global period, so the MUE's wouldn't necessarily apply. I know Medicare has a 90-day rolling period where they will only pay on a certain number of procedures, but I cannot find where in their billing rules it says that.
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I'm not aware of any Medicare rules limiting this type of procedure to a certain number or frequency. I'd recommend contacting Medicare and asking them - they should be able to tell you what other claim is causing this specific denial, or else should direct you the rule that applies to this situation.
 
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I would also question whether the patient had something else done on that last DOS that was causing an issue - for example, did the patient end up being admitted to the hospital? Did they have a procedure or visit on the same day with a different provider who bills under the same Tax ID as you?

They could be denying it as "inclusive" to something you don't even realize exists.

I once had a heck of a time trying to figure out what was causing a visit to deny as inclusive - after months of back and forth, it turned out that the patient had a telehealth visit with another physician under the same tax ID number a few days before our visit. The telehealth visit had already been paid, so they denied my visit as inclusive to that provider's telehealth visit.

(I still fought it, but it was much easier to make an argument once I knew exactly what I was arguing about!)
 
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The referring provider is not eligible to refer the service". what does this mean, patient came to the podiatry office and had x-rays. the xrays were denied with denial The referring provider is not eligible to refer the service". How do i correct this'
 
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